Nokea
The nurse is caring for a client diagnosed with deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care to prevent the complication of pulmonary embolism?
- A. Encourage ambulation as tolerated.
- B. Administer anticoagulants as prescribed.
- C. Apply cold compresses to the affected area.
- D. Encourage the use of incentive spirometry.
Correct Answer: B
Rationale: Administering anticoagulants as prescribed is crucial in preventing the complication of pulmonary embolism in clients with deep vein thrombosis. Anticoagulants help prevent the formation of new clots and the enlargement of existing ones, thereby reducing the risk of a pulmonary embolism. Encouraging ambulation as tolerated is beneficial for preventing complications related to immobility, but it is not the primary intervention to prevent pulmonary embolism in this case. Applying cold compresses to the affected area may help with pain and swelling but does not address the prevention of pulmonary embolism. Encouraging the use of incentive spirometry is more relevant in preventing respiratory complications such as atelectasis, not specifically pulmonary embolism.
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What preoperative instruction should the LPN/LVN reinforce to a client scheduled for a carotid endarterectomy?
- A. You will need to be NPO after midnight before the surgery.
- B. You should avoid deep breathing and coughing after the surgery.
- C. You will be able to eat and drink normally after the procedure.
- D. You can take all of your prescribed medications the morning of surgery.
Correct Answer: A
Rationale: The correct preoperative instruction that the LPN/LVN should reinforce to a client scheduled for a carotid endarterectomy is being NPO after midnight before the surgery. This instruction is essential to prevent aspiration and ensure a safe procedure. Avoiding oral intake helps reduce the risk of complications during anesthesia induction and the surgical process. Choices B, C, and D are incorrect because avoiding deep breathing and coughing, resuming normal eating and drinking, and taking all prescribed medications the morning of surgery are not recommended preoperative instructions for a carotid endarterectomy.
The client is starting therapy with digoxin (Lanoxin). What instruction should the nurse reinforce about the medication?
- A. Take the medication with meals.
- B. Avoid dairy products.
- C. Monitor for yellow or blurred vision.
- D. Increase potassium-rich foods in the diet.
Correct Answer: C
Rationale: The correct answer is C: 'Monitor for yellow or blurred vision.' When a client is taking digoxin, it is crucial to monitor for signs of toxicity, such as yellow or blurred vision, as these can indicate an adverse reaction. Reporting these visual disturbances promptly to the healthcare provider is important for further evaluation and management to prevent potential complications. Choices A, B, and D are incorrect because taking digoxin with meals, avoiding dairy products, or increasing potassium-rich foods are not specific instructions related to monitoring for adverse effects of digoxin therapy.
The healthcare provider is preparing to administer a beta blocker to a client with hypertension. What parameter should be checked before administering the medication?
- A. Serum potassium level
- B. Apical pulse
- C. Oxygen saturation
- D. Pupil reaction to light
Correct Answer: B
Rationale: Before administering a beta blocker, it is crucial to check the apical pulse. Beta blockers have the potential to slow down the heart rate, making it essential to assess the pulse rate to ensure it is within the safe range before giving the medication. Checking the serum potassium level (choice A) is important when administering certain medications, but it is not specifically required before giving a beta blocker. Oxygen saturation (choice C) and pupil reaction to light (choice D) are not directly related to monitoring parameters for beta blocker administration.
The nurse is assisting in the care of a client experiencing an acute myocardial infarction (MI). Which medication would the nurse expect to be administered to help reduce myocardial oxygen demand?
- A. Aspirin
- B. Morphine
- C. Atropine
- D. Lidocaine
Correct Answer: B
Rationale: In the context of an acute myocardial infarction (MI), morphine is administered to relieve pain and reduce myocardial oxygen demand. By alleviating pain and anxiety, morphine helps reduce oxygen demand on the heart, which is beneficial in the setting of an MI. Aspirin, commonly used for its antiplatelet effects, helps inhibit platelet aggregation and is crucial in the management of MI to prevent further clot formation. Atropine is a medication used to treat symptomatic bradycardia by increasing heart rate, not commonly indicated in the management of acute MI. Lidocaine is used for ventricular dysrhythmias and is not typically given to reduce myocardial oxygen demand in an acute MI scenario.
When providing teaching to a client with a new prescription for atorvastatin, which of the following instructions should the nurse include?
- A. Take the medication in the evening.
- B. Take the medication with food.
- C. Increase your intake of grapefruit juice.
- D. Avoid consuming dairy products.
Correct Answer: A
Rationale: The correct instruction for a client with a new prescription for atorvastatin is to take the medication in the evening. Atorvastatin is more effective when taken at night because cholesterol synthesis is higher during this time. This timing helps optimize the drug's cholesterol-lowering effects and enhances its overall efficacy in managing lipid levels. Choices B, C, and D are incorrect. Taking atorvastatin with food can decrease its absorption, grapefruit juice can interact with atorvastatin leading to increased side effects, and there is no specific need to avoid dairy products while on atorvastatin unless instructed otherwise by the healthcare provider.